Annals of the Royal College of Surgeons of England (I979) vol 6i
ASPECTS OF DIAGNOSIS*
Contact cholangiography D C Baxter-Smith MA MSC FRCS Senior Surgical Registrar, Selly Oak Hospital, Birminghamt
M D Middleton MSC
FRCS
FRCSEd
Consultant Surgeon, East Birmingham Hospital, Birmingham
Summary Clinical, operative, and conventional radiological criteria may provide insufficient indications for exploration of the common bile duct. The technique of contact cholangiography improves the radiographic definition, especially in the obese, and has resulted in more positive choledochotomies and in fewer negative explorations.
Introduction Apart from the technical difficulties associated with operations on the biliary tract, one question uppermost in the mind of the surgeon is whether or not the common bile duct requires exploration. This added procedure should not be undertaken lightly as it has a higher morbidity and mortality and involves a more prolonged stay in hospital than cholecystectomy alone'-4. It should be performed only if there is a strong suspicion of a calculus in the biliary tree. Before the introduction of operative cholangiography the indications for choledocotomy were clinical and operative",5. These were: (i) palpable calculi in the common bile duct; (2) a history of jaundice, pancreatitis, or cholangitis; (3) a dilated or thickened common bile duct or cystic duct; (4) multiple small calculi; and (5) thickening or induration of the head of pancreas. These criteria alone were insufficient, and unacceptably high numbers of negative choledochotomies were performed6'9. Operative cholangiography'0"' has provided the surgeon with radiographic indications for exploring the common bile duct. These are: (i) a radiographic diameter of the common bile duct greater than I2 mm; (2) filling defects; (3) no free flow into the duodenum; and
(4) failure to visualise the narrow segment at the lower end of the common bile duct. Even when these criteria are taken in conjunction with the clinical histoiy and operative findings the incidence of negative explorations of the common bile duct, although reduced, remains high'0-14
The radiographic definition of standard operative cholangiography is not always clear enough to establish the presence or absence of a choledochal calculus beyond doubt and any improvement would reduce the incidence of negative choledochotomy. Contact cholangiography was first described by Slattery and Saypol"5 in 1952 and has more recently been revived by Hugh and Campbell"6, but it has not yet found widespread acceptance in modern biliary surgery.
Technique SURGICAL DETAILS
The duodenum is 'Kocherised' using the method of Miller described by McNairl 7 in 196i. This is an extremely quick and reliable method of mobilising the first, second, and third parts of the duodenum along with the head of the pancreas and allows the entire common bile duct to be palpated between the fingers. The left forefinger is inserted into the foramen of Winslow and is gently but forcibly swept inferiorly in a wide arc so that the finger comes to lie behind the second part of the duodenum and is visible deep to the peritoneal reflection lateral to the second part of the duodenum. This is then divided. After the common bile duct has been palpated a cannula is inserted down the cystic duct and conventional on-table cholangiography performed. We have used 3 ml of 45 % Hypaque (sodium diatrizoate). After the film has been removed from the table a Kodak D3 (29) Dentech occlusal film, sterilised for I5 min in Cidex (2% glutaraldehyde, buffered) solution, is placed behind the second and third parts of the duodenum and the head of pancreas and as far up behind the supraduodenal portion of the common bile duct as possible. Care must be taken tPresent address: Queen Elizabeth Hospital, not to bend the film during this procedure; otherwise artefact 'crimp' marks can spoil the radiograph. Birmingham The Editor would welcome any observations on this paper from readers *Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor
374
D C Baxter-Smith and M D Middleton
_t
FIG. I Left-typical operative cholangiogram which fails to demonstrate clearly the lower end of the common duct. Rightcontact cholangiogram
showing improved defin-
ition of lower end of common bile duct.
This film is then exposed and removed. A further 3 ml of Hypaque is injected and the procedure repeated. With experience it is possible for the surgeon to guarantee correct positioning of the film to show the lower end of the common bile duct. After the film has been inserted behind the duodenum and the duodenum allowed to fall back into its natural position there is a tendency for this organ to fall too far laterally in relation to the film. The positioning of the film is the most difficult part of the procedure and the one which is likely to cause the surgeon to dismiss it as impracticable. RADIOGRAPHIC DETAILS
The films are exposed coning to an area slightly larger than the film size using factors of 6o kVp at 30 mAs with a focal-film distance of 27 in (70 cm). Manual processing is carried out for 3 min at 680 F (200 C) using Kodak DX developer and Kodak FX 40 fixer. The films are washed for 30 s in running water and, after viewing, are refixed and washed in running water for a further 30 min. More details of the radiographic technique are described elsewhere'8.
Results Operative cholangiography and contact cholangiography have been performed during the course of 86 routine cholecystectomies. Seven technical failures in the early part of the series meant that no information was available from the contact cholangiograms in these cases. Incorrect positioning of the occlusal film was responsible for 3 of the failures and inaccurate radiographic exposures spoiled a further 4 films.
Improved radiographic definition was obtained in the 79 technically successful contact cholangiograms. A typical example is shown in Figure I. Multiple small gallstones were found in the gallbladder and routine operative cholangiography failed to demonstrate clearly the narrow segment at the lower end of the common bile duct. Using conventional operative and radiological criteria as defined"2"'0 exploration of the common duct would have been justified. However, the contact cholangiogram improved the radiographic definition to such a degree that the lower end of the duct was clearly seen (as well as a small length of pancreatic duct) and obviated the need for exploration. There were no clinical or operative indications for exploring the common bile duct shown in Figure 2 and, although at the upper limit of normal radiological calibre (I 2 mm), it was adjudged to be satisfactory by the consultant surgeon performing the operation and the consultant radiologist who examined the conventional operative cholangiogram. The contact radiograph, however, clearly demonstrated the presence of a calculus in the duct and this was subsequently extracted at the same operation. Using the information obtained from standard operative cholangiography 22 explorations would have been perfonned and in 8 of
Contact cholangiography these stones would have been found. Fourteen explorations would have been unnecessary. The combined information provided by the conventional operative cholangiograms and contact cholangiograms indicated the need for exploration in i3 ducts, thus preventing 9 unnecessary explorations. In I0 of the I3 ducts explored calculi were retrieved (that is, 2 more than would otherwise have been discovered). Only 3 negative choledochotomies were carried out.
In this series there has been no morbidity directly related to the technique of contact cholangiography and so far as is known there have been no instances of retained calculi.
Discussion Whereas the operation of cholecystectomy alone has a low morbidity, the added procedure of choledochotomy increases both the morbidity and the mortality of the operation. Infection is the main reason for these differences4. Bartlett and Waddell' showed a mortality of o.6/o for cholecystectomy alone, but in those patients whose common bile duct had also been explored the mortality was i.8%. In the series reported by Hight' comparable mortality figures of o.07o for cholecystectomy and 2.070 foi cholecystectomy with duct exploration were obtained and the average postoperative stay in hospital was 8 days and I9.9 days respectively.
375
Unnecessary choledochotomy is to be avoided whenever possible. Before the introduction of operative cholangiography clinical and operative criteria provided the surgeon's main indications for duct exploration, but a survey of the literature69 shows the large percentages (31-7I7o) of unnecessary explorations performed. Even with conventional operative cholangiography'014, although the incidence of unproductive choledochotomies is reduced (27-50%), the radiographic definition may be insufficient to provide all the information desired. The technique of contact cholangiography has improved in the past 25 years. The prewrapped Dentech occlusal films are ideally suited for the technique and the results obtained show the improved definition that can be obtained. The reasons for this are threefold: (i) there is a reduced distance between the biliary tract and the radiographic plate, especially in the obese; (2) there can be no chance of superimposition of the spinal column between the biliary tract and the radiographic plate and therefore no need to tilt the operating table; and (3) any movement of the duodenum or biliary tract may be transmitted to the radiographic plate and thus reduce distortion should respiration or peristalsis occur during exposure of the film. The technique is simple, safe, quick, and in-
2 Left-operative cholangiogram not obviously demonstrating the presence of a calculus. Right-contact cholangiogram clearly demonstrating
FIG.
N
calculus.
376
D C Baxter-Smith and M D Middleton
expensive and our results show that the combined information of operative cholangiography and contact cholangiography can reduce the incidence of the 'overlooked stone' and of unnecessary exploration of the common bile duct.
References I
2 3
+ 5
Bartlett, M K, and Waddell, W R (I958) New England Journal of Medicine, 258, I64. Havard, C (I960) Annals of the Royal College of Surgeons of England, 26, 88. Hight, D, Lingley, J R, and Hurtubise, F (I959) Annals of Surgery, I50, io86. Keighley, M R B, and Graham, N G (I970) British Journal of Surgery, 58, 764. Buxton, R W, and Burk, L B (1948) Surgery, 23,
760.
6 Lahey, F H (1932) New England Journal of Medicine, 207, 685.
7 Cattell, R B (I948) Surgical Clinics of North America, 28, 659. 8 Walters, W, Gray, H K, and Priestley, J T (I948) Proceedings of the Mayo Clinic, 23, 40. 9 Glenn, F (1940) Annals of Surgery, 112, 64. io Le Quesne, L P (I960) Proceedings of the Royal Society of Medicine, 53, 852. i i Faris, I, Thompson, J P S, Grundy, D J, and Le Quesne, L P (I975) British Journal of Surgery, 62, 966. I2 Nienhuis, L I (I96I) Annals of Surgery, I54, 192. I3 McEvedy, B V (I970) British Journal of Surgery, 57, 277. I4 Domellbf, L, Rydh, A, and Truedson, H (I977) British Journal of Surgery, 64, 862. I5 Slattery, L R, and Saypol, G M (1952) American Journal of Surgery, 84, 229. i6 Hugh, T B, and Campbell, T J (1976) American Journal of Surgery, I32, 562. I7 McNair, T J (I96I) British Journal of Surgery, 49, I 98.
I8 Hogg J F, Middleton, M D, and Baxter-Smith, D C (1978) Radiography, 44, 71.
ASPECTS OF DIAGNOSIS*
Contact cholangiography D C Baxter-Smith MA MSC FRCS Senior Surgical Registrar, Selly Oak Hospital, Birminghamt
M D Middleton MSC
FRCS
FRCSEd
Consultant Surgeon, East Birmingham Hospital, Birmingham
Summary Clinical, operative, and conventional radiological criteria may provide insufficient indications for exploration of the common bile duct. The technique of contact cholangiography improves the radiographic definition, especially in the obese, and has resulted in more positive choledochotomies and in fewer negative explorations.
Introduction Apart from the technical difficulties associated with operations on the biliary tract, one question uppermost in the mind of the surgeon is whether or not the common bile duct requires exploration. This added procedure should not be undertaken lightly as it has a higher morbidity and mortality and involves a more prolonged stay in hospital than cholecystectomy alone'-4. It should be performed only if there is a strong suspicion of a calculus in the biliary tree. Before the introduction of operative cholangiography the indications for choledocotomy were clinical and operative",5. These were: (i) palpable calculi in the common bile duct; (2) a history of jaundice, pancreatitis, or cholangitis; (3) a dilated or thickened common bile duct or cystic duct; (4) multiple small calculi; and (5) thickening or induration of the head of pancreas. These criteria alone were insufficient, and unacceptably high numbers of negative choledochotomies were performed6'9. Operative cholangiography'0"' has provided the surgeon with radiographic indications for exploring the common bile duct. These are: (i) a radiographic diameter of the common bile duct greater than I2 mm; (2) filling defects; (3) no free flow into the duodenum; and
(4) failure to visualise the narrow segment at the lower end of the common bile duct. Even when these criteria are taken in conjunction with the clinical histoiy and operative findings the incidence of negative explorations of the common bile duct, although reduced, remains high'0-14
The radiographic definition of standard operative cholangiography is not always clear enough to establish the presence or absence of a choledochal calculus beyond doubt and any improvement would reduce the incidence of negative choledochotomy. Contact cholangiography was first described by Slattery and Saypol"5 in 1952 and has more recently been revived by Hugh and Campbell"6, but it has not yet found widespread acceptance in modern biliary surgery.
Technique SURGICAL DETAILS
The duodenum is 'Kocherised' using the method of Miller described by McNairl 7 in 196i. This is an extremely quick and reliable method of mobilising the first, second, and third parts of the duodenum along with the head of the pancreas and allows the entire common bile duct to be palpated between the fingers. The left forefinger is inserted into the foramen of Winslow and is gently but forcibly swept inferiorly in a wide arc so that the finger comes to lie behind the second part of the duodenum and is visible deep to the peritoneal reflection lateral to the second part of the duodenum. This is then divided. After the common bile duct has been palpated a cannula is inserted down the cystic duct and conventional on-table cholangiography performed. We have used 3 ml of 45 % Hypaque (sodium diatrizoate). After the film has been removed from the table a Kodak D3 (29) Dentech occlusal film, sterilised for I5 min in Cidex (2% glutaraldehyde, buffered) solution, is placed behind the second and third parts of the duodenum and the head of pancreas and as far up behind the supraduodenal portion of the common bile duct as possible. Care must be taken tPresent address: Queen Elizabeth Hospital, not to bend the film during this procedure; otherwise artefact 'crimp' marks can spoil the radiograph. Birmingham The Editor would welcome any observations on this paper from readers *Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor
374
D C Baxter-Smith and M D Middleton
_t
FIG. I Left-typical operative cholangiogram which fails to demonstrate clearly the lower end of the common duct. Rightcontact cholangiogram
showing improved defin-
ition of lower end of common bile duct.
This film is then exposed and removed. A further 3 ml of Hypaque is injected and the procedure repeated. With experience it is possible for the surgeon to guarantee correct positioning of the film to show the lower end of the common bile duct. After the film has been inserted behind the duodenum and the duodenum allowed to fall back into its natural position there is a tendency for this organ to fall too far laterally in relation to the film. The positioning of the film is the most difficult part of the procedure and the one which is likely to cause the surgeon to dismiss it as impracticable. RADIOGRAPHIC DETAILS
The films are exposed coning to an area slightly larger than the film size using factors of 6o kVp at 30 mAs with a focal-film distance of 27 in (70 cm). Manual processing is carried out for 3 min at 680 F (200 C) using Kodak DX developer and Kodak FX 40 fixer. The films are washed for 30 s in running water and, after viewing, are refixed and washed in running water for a further 30 min. More details of the radiographic technique are described elsewhere'8.
Results Operative cholangiography and contact cholangiography have been performed during the course of 86 routine cholecystectomies. Seven technical failures in the early part of the series meant that no information was available from the contact cholangiograms in these cases. Incorrect positioning of the occlusal film was responsible for 3 of the failures and inaccurate radiographic exposures spoiled a further 4 films.
Improved radiographic definition was obtained in the 79 technically successful contact cholangiograms. A typical example is shown in Figure I. Multiple small gallstones were found in the gallbladder and routine operative cholangiography failed to demonstrate clearly the narrow segment at the lower end of the common bile duct. Using conventional operative and radiological criteria as defined"2"'0 exploration of the common duct would have been justified. However, the contact cholangiogram improved the radiographic definition to such a degree that the lower end of the duct was clearly seen (as well as a small length of pancreatic duct) and obviated the need for exploration. There were no clinical or operative indications for exploring the common bile duct shown in Figure 2 and, although at the upper limit of normal radiological calibre (I 2 mm), it was adjudged to be satisfactory by the consultant surgeon performing the operation and the consultant radiologist who examined the conventional operative cholangiogram. The contact radiograph, however, clearly demonstrated the presence of a calculus in the duct and this was subsequently extracted at the same operation. Using the information obtained from standard operative cholangiography 22 explorations would have been perfonned and in 8 of
Contact cholangiography these stones would have been found. Fourteen explorations would have been unnecessary. The combined information provided by the conventional operative cholangiograms and contact cholangiograms indicated the need for exploration in i3 ducts, thus preventing 9 unnecessary explorations. In I0 of the I3 ducts explored calculi were retrieved (that is, 2 more than would otherwise have been discovered). Only 3 negative choledochotomies were carried out.
In this series there has been no morbidity directly related to the technique of contact cholangiography and so far as is known there have been no instances of retained calculi.
Discussion Whereas the operation of cholecystectomy alone has a low morbidity, the added procedure of choledochotomy increases both the morbidity and the mortality of the operation. Infection is the main reason for these differences4. Bartlett and Waddell' showed a mortality of o.6/o for cholecystectomy alone, but in those patients whose common bile duct had also been explored the mortality was i.8%. In the series reported by Hight' comparable mortality figures of o.07o for cholecystectomy and 2.070 foi cholecystectomy with duct exploration were obtained and the average postoperative stay in hospital was 8 days and I9.9 days respectively.
375
Unnecessary choledochotomy is to be avoided whenever possible. Before the introduction of operative cholangiography clinical and operative criteria provided the surgeon's main indications for duct exploration, but a survey of the literature69 shows the large percentages (31-7I7o) of unnecessary explorations performed. Even with conventional operative cholangiography'014, although the incidence of unproductive choledochotomies is reduced (27-50%), the radiographic definition may be insufficient to provide all the information desired. The technique of contact cholangiography has improved in the past 25 years. The prewrapped Dentech occlusal films are ideally suited for the technique and the results obtained show the improved definition that can be obtained. The reasons for this are threefold: (i) there is a reduced distance between the biliary tract and the radiographic plate, especially in the obese; (2) there can be no chance of superimposition of the spinal column between the biliary tract and the radiographic plate and therefore no need to tilt the operating table; and (3) any movement of the duodenum or biliary tract may be transmitted to the radiographic plate and thus reduce distortion should respiration or peristalsis occur during exposure of the film. The technique is simple, safe, quick, and in-
2 Left-operative cholangiogram not obviously demonstrating the presence of a calculus. Right-contact cholangiogram clearly demonstrating
FIG.
N
calculus.
376
D C Baxter-Smith and M D Middleton
expensive and our results show that the combined information of operative cholangiography and contact cholangiography can reduce the incidence of the 'overlooked stone' and of unnecessary exploration of the common bile duct.
References I
2 3
+ 5
Bartlett, M K, and Waddell, W R (I958) New England Journal of Medicine, 258, I64. Havard, C (I960) Annals of the Royal College of Surgeons of England, 26, 88. Hight, D, Lingley, J R, and Hurtubise, F (I959) Annals of Surgery, I50, io86. Keighley, M R B, and Graham, N G (I970) British Journal of Surgery, 58, 764. Buxton, R W, and Burk, L B (1948) Surgery, 23,
760.
6 Lahey, F H (1932) New England Journal of Medicine, 207, 685.
7 Cattell, R B (I948) Surgical Clinics of North America, 28, 659. 8 Walters, W, Gray, H K, and Priestley, J T (I948) Proceedings of the Mayo Clinic, 23, 40. 9 Glenn, F (1940) Annals of Surgery, 112, 64. io Le Quesne, L P (I960) Proceedings of the Royal Society of Medicine, 53, 852. i i Faris, I, Thompson, J P S, Grundy, D J, and Le Quesne, L P (I975) British Journal of Surgery, 62, 966. I2 Nienhuis, L I (I96I) Annals of Surgery, I54, 192. I3 McEvedy, B V (I970) British Journal of Surgery, 57, 277. I4 Domellbf, L, Rydh, A, and Truedson, H (I977) British Journal of Surgery, 64, 862. I5 Slattery, L R, and Saypol, G M (1952) American Journal of Surgery, 84, 229. i6 Hugh, T B, and Campbell, T J (1976) American Journal of Surgery, I32, 562. I7 McNair, T J (I96I) British Journal of Surgery, 49, I 98.
I8 Hogg J F, Middleton, M D, and Baxter-Smith, D C (1978) Radiography, 44, 71.
